Physical Exam: Musculoskeletal System

I. History: Participation in sports, risk factors for osteoporosis, impact of current problem on activities of daily living


II. Inspection

• Gait: Normal findings - client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with push off and swing through
• Posture and Balance: Normal findings

1. upright stance with parallel alignment  of hips and shoulders
2. feet aligned; toes pointing straight ahead
3. convex curve to thoracic spine
4. concave curve to lumbar spine
5. can stand still without swaying or tilting

• Extremities: Normal findings - bilateral symmetry in length, circumference. alignment, position and number of skin folds

III. Palpation

• All muscles, bones, joints
• Normal findings - muscles firm, non-tender

IV. Range of Motion: Normal findings - able to move joints through required range of motion

• Abduction - lateral movement of the limbs away from the median plane of the body, or lateral bending of the head or trunk
• Adduction - movement of a limb or eye toward the median plane of the body or, in the case of digits, toward the axial line of a limb
• Dorsiflexion - movement of a part at a joint to bend the part toward the dorsum, or posterior aspect of the body
• Eversion - turning outward
• Extension - a movement that brings the members of a limb into or towards a straight position
• Flexion - the act of bending or condition of being bent in contrast to extension
• Hyperextension - extreme or abnormal extension
• Inversion - a turning inside out of an organ (e.g. the uterus)
• Plantar flexion - extension of the foot so that the forepart is depressed with respect to the position of the ankle
• Pronation - the act of lying prone or face downward
• Supination - the condition of being on the back of having the palm of the hand facing upward or the foot turned inward and upward

V. Muscle Strength and Symmetry: Normal findings - arm on dominant side generally stronger

VI. Alterations

• Kyphosis - exagerration or angulation of the normal posterior curve of the spine, giving rise to the condition commonly known as humpback. hunchback or Pott's curvature
• Lordosis - abnormal anterior convexity  of the lumbar spine
• Scoliosis - lateral curvature of the spine
• Pain

VII. Geriatric Alterations

• Stance less upright with head and neck forward
• Lumbar curvature less pronounced
• Height decreased
• Gait slower to initiate and stop
• Less knee and ankle lifts
• Steps may be shorter and more rapid
• May need to hold unto furniture as age increases
• Muscles atrophy with disuse
• Weaker grip
• Active range of motion may be slower and limited in one or more joints
• Joints appear larger than surrounding tissue; may be stiff

POINT TO REMEMBER:

• Older adults walk with smaller steps and need a wider base of support

Physical Exam: Male Reproductive System

I. History: Sexual history, sexually transmitted disease, contraception, surgery, associated urinary problems

• External genitalia
• Hair distribution: varies; hair extends from base of penis over symphysis pubis; coarse and curly
• Penis shaft, corona, prepuce, glans
• Urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of glans; opening should be glistening and pink
• Scrotum:

1. skin more darkly pigmented; more wrinkled; usually loose
2. symmetry - left testicle is lower than right
3. size - changes with temperature

• Inguinal canal: no finding - no bulging

II. Palpation

•  Penis:

1. foreskin should retract easily
2. small amount of thick white secretion between glans and foreskin is normal
3. testicle - ovoid; ranges from 2-4 cm in diameter, smooth and rubbery; nontender

• Inguinal canal: Normal finding - inguinal lymph nodes not palpable

III. Geriatric Alterations

• Increased bogginess of prostrate
• Testes softer

IV. Rectum and Anus

• Inspection of perianal areas

1. skin - smooth and uninterrupted
2. anal tissues - normally moist and hairless

• Digital palpation:

1. Anal sphincter - note tone
2. Rectal walls - smooth and even
3. Prostrate gland = Palpate through anterior rectal wall; Small walnut-sized, heart shaped structure; Ranges from 2.5 to 4 cm in diameter; Normal findings - firm, protrudes <1 cm into rectum

• Alterations:

1. fissures
2. fistulas
3. polyps
4. pain
5. hemorrhoids

PhotoCredit: hemorrhoidtreatmentanswers.com

Physical Exam: Female Reproductive System

I. History: sexually transmitted disease, menstrual history, obstetrical history, contraception

II. Inspection

• External genitalia: Normal findings

1. hair distribution: variable; usually inverted triangle starting at symphysis pubis
2. skin of perineum smooth, clean, slightly darker than other skin
3. labia majora - may be closed or gaping
4. clitoris - about 2 cm in length and 0.5 cm in width
5. urethral orifice - intact, pink without irritation
6. vaginal orifice - ranges from thin, vertical slit to larger orifice with moist tissue
7. anus - moist and hairless - skin more darkly pigmented

• Internal genitalia:

1. Cervix - normal findings: pink; midline; usually about 2 to 3 cm in diameter; smooth, firm, rounded or oval; odorless, creamy or clear secretions
2. papanicolau (Pap) smear
3. vagina - pink throughout; clear or cloudy, odorless secretions; about 10 to 15 cm in length

III. Palpation

• Ovaries may or may not be palpable; firm, slightly tender, oval, mobile; about 4 cm in diameter
• Uterus - mobile; rounded; palpable at level of pelvis
• Skene's glands and Bartholin's gland - normal findings: nontender, no discharge

IV. Geriatric Alterations

• Labial folds flatten
• Skin paler, shiny
• Meatus usually more posterior
• Cervix decreases in size; may appear paler
• Scanty cervical discharge
• Vagina shortens with age
• Decreased vaginal secretions
• Uterus diminishes in size; may not be palpable
• Ovaries atrophy with age

Physical Exam: Abdomen

I. History

• Pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence, belching, heartburn, nausea, vomiting, cramping
• Changes in micturition including: change in amount and color of urine, irritation of lower urinary tract, urinary incontinence, urinary tract pain

II. Inspection

• Landmarks: 

1. Xiphoid process - marks upper boundary of abdomen 
2. Symphysis pubis - marks lower boundary 
3. Abdomen divided into four quadrants - RUQ, RLQ, LUQ, LLQ

• Normal findings: 

1. skin texture and color should be consistent with rest of body
2. striae may be present
3. umbilicus is normally flat or concave midway between xiphoid and symphysis pubis
4. abdomen may be flat, concave or convex; all three are normal if there is symmetry
5. you may not peristalsis movement or aortic pulse
6. voiding - steady, straight stream with no pain or post void dribble

III. Percussion

• Normal findings: Tympany over stomach and intestines; dullness over liver, spleen, pancreas, kidneys and distended (>150 cc) bladder
• Liver border:

1. usually noted in the 5th, 6th or 7th intercostal space
2. distance between upper and lower borders should range between 6 to 12 cm at right midclavicular line

• Spleen:

1. Left posterior midaxillary line - dullness at 6th to 10th rib
2. Left intercostal space in anterior axillary line - tympany

IV. Palpation

• Normal findings: soft with no palpable masses, no tenderness or rigidity
• Bladder noted as a bulge in abdomen when filled with more than 500cc of urine
• Deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not palpable

V. Auscultation

• Bowel motility: normal findings - audible in all quadrants
• Vascular sounds: normal findings

1. no vascular sounds over aorta or femoral arteries
2. renal artery bruits can be heard

VI. Alterations

• Distention
• Ascites
• Paralytic ileus
• Borborygmus
• Guarding (muscle contract)
• Tenderness
• Pain

VII. Geriatric Alterations

• Increased fat deposits over abdominal area
• Muscle tone more lax

POINTS TO REMEMBER:

• Auscultation should be performed before palpation to prevent distortion of bowel sounds
• Tightening of abdominal muscles hinders accuracy of palpation and auscultation
• Warm hands before touching client's abdomen
• Men breathe abdominally; women breathe costally
• Auscultate all four quadrants for bowel sounds
• Auscultate abdomen between meals

Physical Exam: Breasts

I. Inspection (Performed with client in lying, sitting or standing position)

• Size: Vary from convex to pendulous
• Symmetry: (The breast in the same side as your dominant hand is commonly larger than the other)
• Skin: Color, venous pattern, possibly a few hairs around areola
• Alterations:

1. retractions
2. dimpling
3. lesions
4. edema
5. inflammation

• Alterations with Pregnancy and Lactation:

1. enlargement of breasts
2. soreness of nipples during lactation
3. possible striae

• Nipple and areola:

1. size
2. color - ranges from pink to brown
3. shape - areola round or oval; nipples everted
4. symmetry - normally symmetrical
5. direction - normally nipples point in same direction
6. alterations - discharge; inverted nipples; bleeding

II.Palpation - Breast

• Lymph nodes: Normal findings - not palpable
• Breast tissue

Client should be in supine position with hand placed behind the neck.

• Methods of Examining Breast:

1. Clockwise or counterclockwise circling breast from nipple outward
2. Back and forth with fingers moving up and down each breast

• Consistency:

1. varies widely from person to person
2. Normal findings - dense, firm, and elastic

• Alterations: fibrocystic disease of the breast
• Geriatric alterations:

1. relaxed breasts 
2. may appear elongated or pendulous
3. decrease in glandular tissue

POINTS TO REMEMBER:

• Breast tissue shrinks with menopause
• Teach client breast self examination:

Physical Exam: Lungs

I. History: smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever
II. Inspection


General Appearance: Respiration

• Breathing should be quiet and easy
• Respiration involves ventilation, diffusion, and perfusion of gases
• Factors influencing respirations: exercise, pain, anxiety, stress, anemia, posture, drugs (narcotics, amphetamine)
• Normal Rates of Respiration: Newborn - 35 to 40 breaths/minute; Infant - 30 to 50 breaths/minute; Toddler - 25 to 35 breaths/minute; Schoolage - 20 to 30 breaths/minute; Adolescent - 14 to 20 breaths/minute; Adult - 12 to 20 breaths/minute
• Depth: deep, normal, shallow
• Rhythm: regular, irregular; Normal Finding: regular
• Skin color
• Chest wall configuration: Normal Findings - symmetrical with bilateral muscle development; A-P Transverse Ration = 1-5:2-7

III. Palpation

• Feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry
• Crepitus indicates air in subcutaneous space (in thoracic area, usually due to pneuomothorax)
• Vocal fremitus: Vibration felt when patient speaks; Increased over areas of consolidation

IV. Percussion

• Normal findings: resonance heard throughout lung fields

V. Auscultation

• Normal findings: quiet breathing throughout all lung fields
• Whispered pectoriloquy:

1. Client whispers "One, two, three" 
2. Over normal areas of the lung, only faint sounds are heard
3. Over consolidated areas, the words are more distinct

• Egophony:

1. Client says "E"
2. Over consolidated areas, the sound is a nasal "A"

VI. Alterations in Lung Function

• Cough
• Expectoration
• Dyspnea
• Bradypnea
• Tachypnea
• Hyperpnea
• Apnea
• Cheyne-Stoke respiration
• Kussmaul's breathing
• Biot's breathing
• Grunting
• Retractions
• Hemoptysis
• Pain
• Accessory muscle use
• Cyanosis
• Adventitious sounds
• Pursed-lip breathing:

1. Prolonged exhalation
2. Breathing out through puckered lips

• Pleural friction rub:

1. Grating sound produced by inflamed pleura rubbing together
2. Usually heard loudest over lower lateral anterior chest at end of inspiration

VII. Pediatric Differences

• Smaller, shorter, more pliable airways
• Underdeveloped supporting cartilage
• Above two factors increase the risk of obstruction due to mucus, edema or foreign body
• Flexible larynx more susceptible to spasm
• Immature immune system
• Incomplete myelinization
• Increased basal metabolic rate
• Decreased ability to mobilize secretions
• Less forceful cough

POINTS TO REMEMBER:

• Anemic patients may never become cyanotic
• Polycythemic patients may become cyanotic, even when oxygenation is normal
• Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology
• Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin
• Wheezes indicates narrowing/inflammatory process of lower airways
• Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough"
• Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation

Physical Exam: Vasculature

I. Blood Pressure

• Reflects relationship between cardiac output, peripheral vascular resistance, blood volume and viscosity and arterial elasticity
• Factors influencing Blood Pressure: age, stress, race, drugs, diurnal (day-night) variations, gender
• Alterations in Blood Pressure: Hypotension, Hypertension
• Range of Normal Blood Pressure:

1. Child under age 2 weighing at least 2700 grams - use flush technique, 30-60 mmHg
2. Child over age two - 85-95/50-65 mmHg
3. School age - 100-110/50-65 mmHg
4. Adolescent - 110-120/65-85 mmHg
5. Adult - <130 mmHg systolic/ <85 mmHg diastolic

Common Mistakes during Upper Extremity Blood Pressure Checks

• Too wide bladder or cuff produces false low reading
• Too narrow bladder or cuff produces false high reading
• Cuff wrapped too loosely produces false high reading
• Deflating cuff too slowly produces false high reading
• Deflating cuff too quickly produces false low systolic and false high diastolic reading
• Inaccurate inflation level produces false low systolic reading
• Taking the blood pressure in lower extremities

Peripheral Blood Pressure Measurement in the Legs

• Use the popliteal artery behind knee as stethoscope ausculatory site
• Position the client prone or sitting with knees slightly flexed
• Use wide, long cuff; wrap it so that the bladder is over the posterior aspect of midthigh
• Systolic blood pressures in legs are 20-40 mmHg higher than in the brachial artery
• Diastolic pressure in the legs is about the same as in the brachial artery

II. Internal Carotid Arteries in the Neck

• Palpate each separately along margin of sternocleidomastoid muscle
• Normal findings: strong thrusting pulse
• Auscultate both sides
• Normal findings: no sound heard
• Constriction cause bruit

III. Jugular Veins

• Client in supine position with head elevated at 45 degrees
• Normal findings: pulsations not evident
• Jugular Venous Pressure (JVP): not to exceed 3 cm above level of sternal angle

IV. Peripheral Arteries and Veins

PULSE

Location of Pulses

Head and Neck

• Temporal: over temporal bone lateral to eye
• Carotid: over the carotid artery in neck

Chest

• Apical: between 4th and 5th intercostal space usually mid-clavicular line

Arm

• Brachial: in anterocubital area of arm
• Radial: on thumb side of wrist
• Ulnar: medial wrist

Leg

• Femoral: below the inguinal ligament
• Popliteal: behind knee
• Posterior Tibial: on inner side of each ankle
• Dorsalis Pedis: along top of foot

Normal Peripheral Pulse Range

• Infants: 120-160 beats per minute
• Toddlers: 90-140 beats per minute
• Preschool/School-age: 74-110 beats per minute
• Adolescent/Adult: 60-100 beaths per minute

Factors Affecting Rate

• Exercise
• Temperature
• Stress
• Drugs
• Hemorrhage
• Postural changes
• Pulmonary conditions causing poor oxygenation

Rhythm - regular (normal) or irregular

Strength

• Reflects volume of blood ejected with each beat
• Grading system

Pulse Grading Scale

• No Pulse = 0
• Weak Pulse = 1+
• Difficult to Palpate = 2+
• Normal = 3+
• Bounding = 4+

Equality

Alterations

Dysrhythmias

Tissue Perfusion

• Temperature
• Color: cyanosis
• Clubbing
• Skin and nail texture
• Hair distribution on lower extremities
• Presence of ulcers
• Edema

Pittine Edema Grading Scale

• 4+ = Indentation of >10 mm; greater than 1 inch (Severe)
• 3+ = Indentation of 5-10 mm; 1/2 to 1 inch pitting (Severe)
• 2+ = Indentation of <5mm; 1/4 to 1/2 inch pitting (Moderate)
• 1+ = Barely detectable; 0 to 1/4 inch pitting (Mild)

POINTS TO REMEMBER:

• Compare blood pressure in arms left versus right
• Compare blood pressure with client lying, sitting and standing

Physical Exam: Heart

I. Assess the heart through the anterior thorax (front chest)
II. Inspection and palpation

• Client in supine position or with head elevated at 45 degrees
• Anatomical landmarks of the heart: 

1. Second Right Intercostal Space - Aortic Area
2. Second Left Intercostal Space - Pulmonic Area 
3. Third Left Intercostal Space - Erb's Point
4. Fourth Left Intercostal Space - Tricuspid Area
5. Fifth Left Intercostal Space - Mitral (Apical) Area
6. Epigastric Area at tip of sternum

• Apical Impulse:

1. 4-5th Left intercostal space, midclavicular line
2. may or may not be seen
3. normally a short, gentle tap

III. Auscultation

• Client takes 3 positions: sitting, supine, left lateral recumbent
• Use stethoscope to auscultate heart sounds
• S1 - closing of the mitral valve; after long diastolic pause; before short systolic pause; heard best at apex
• S2 - closing of aortic valve; after short systolic pause; before long diastolic pause; heard best over aorta (second right intercostal space)
• Pulse deficit
• Murmurs

1. Grading system
2. Asymptomatic or symptomatic
3. Thrill
4. Systolic murmur occurs between S1 and S2
5. Diastolic occurs between S2 and S1

Classifying Heart Murmurs by Intensity

• Grade I: Difficult to hear, even with stethoscope
• Grade II: Quiet, heard with stethoscope
• Grade III: Moderately loud, no thrill
• Grade IV: Loud, may have a thrill
• Grade V: Very loud, heard with a stethoscope partially off chest; has thrill
• Grade VI: Can be heard with a stethoscope off the chest; has thrill 

Physical Exam: Skin

General Appearance - Inspection
I. Color

• Varies with body part, and from person to person
• Color ranges: "white" skin - ivory or light pink to ruddy pink; dark skin - light to dark brown or olive

II. Alterations in Skin Color

• Hyperpigmentation
• Hypopigmentation
• Cyanosis
• Jaundice
• Erythema

III. Moisture

IV. Temperature

V. Texture: Varies from part to part

• Smooth or rough
• Supple or tight
• Indurated

VI. Turgor

• Normally decreases with age
• Decreased in dehydration

VII. Vascularity

• In older people. capillaries are more fragile
• Petechiae

VIII. Edema

IX. Lesions

• Normal Finding: free of lesions
• Age-related changes include keratosis senilis, cherry angiomas, and atrophic warts
• Primary Lesions:

1. Macule - discolored spot or patch on the skin, neither elevated nor depressed, of various colors, sizes, and shapes
2. Papule - small, red, elevated area on the skin, solid and circumscribed; a pimple
3. Patch - small circumscribed area distinct from the surrounding surface in character and appearance
4. Plaque - patch on the skin or on a mucous surface
5. Vesicle - small sac or bladder containing fluid; a blisterlike small elevation on the skin containing serous fluid
6. Bulla - large blister or skin vesicle filled with fluid; a bleb
7. Pustule - small elevation of the skin filled with lymph or pus
8. Nodule - small node

• Secondary Lesions: (arise from primary)

1. scale
2. crust
3. lichenification
4. scar
5. excoriation
6. ulcer
7. fissure
8. keloid
9. erosion

• For every lesions, note eight (8) aspects

1. color
2. location
3. texture
4. size
5. shape
6. type
7. grouping
8. distribution

X. Hair

• Hirsutism
• Alopecia

XI. Nails

XII. Factors Affecting Skin Condition

• Hygiene
• Nutritional status
• Underlying disorders

XIII. Geriatric Changes in Skin (besides wrinkling, and loss/graying of both head and body hair)

• Thinner skin
• More freckles
• Hypopigmented patches
• Skin is drier, especially on lower extremities
• Less perspiration
• All skin becomes less elastic; hanging parts sag
• Toenails may be thick, distorted and yellowish
• Lesions: cherry angiomas, senile keratosis, atrophic warts

Physical Exam: Mouth and Pharynx

I. Inspection: Normal findings

• Temporomandibular joint: smooth jaw excursion; easy mobility
• Lips and buccal mucosa: symmetrical, pink; smooth and moist
• Teeth and gums: 32 adult teeth; pink gums
• Tongue: symmetry, pink, moist; papilla present
• Hard and soft palate: hard palate is pale, immovable with transverse rugae; soft palate is pink and movable
• Oropharynx: symmetrical; midline uvula, tonsils may be present on either side

II. Geriatric Alterations

• Mucosa may be drier
• Sense of taste may be diminished
• Decreased saliva
• Lips thinner, shiny
• Teeth may appear yellowish
• Tongue may appear smoother

Physical Exam: Ears

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I. History

• Presenting problem or injury
• Presence of hearing loss
• Use of hearing assist
• Associated findings
• Onset
• Precipitating factors
• Aggravating and alleviating factors
• Lifestyle factors: swimming, musician
• Medical history
• Family history of allergy or hearing disease
• Medications

II. Inspection - External Ear

• Observe size, shape and symmetry of both ears
• Auricles are normally level with each other, and upper point of attachment is in a straight line with the lateral canthus of the eye
• Inspect ear skin for color, lesions, rash and scaling
• Inspect area behind auricle for tophus (a deposit of sodium biurate in tissues near a joint, in the ear, or in bone in gout)

III. Palpation

• Palpate auricle, tragus and mastoid area for tenderness and elevated local temperature
• Normal findings: auricle is normally smooth without lesions
• Estimate size of external auditory meatus

IV. Otoscopic Examination

• Adult: Grasp auricle and pull UP and BACK to straighten external ear canal before inserting otoscope
• Child: Grasp auricle and pull DOWN and BACK
• Inspect ear canal for redness, swelling, discharge, crusting and foreign bodies
• Expect a small amount of moist, usually orange cerumen (ear wax). Cerumen is usually dry in Asians, Native Americans and the elderly
• Tympanic Membrane: 

1. Normal Finding: translucent, shiny, light gray, taut disk; free from tears or breaks
2. Test its mobility: Ask client to say "ah" or swallow. Intact membrane will vibrate slightly

V. Hearing Acuity: Four Tests

1. Gross hearing is tested by client's response to normal conversation
2. Whispered words or ticking watch test
3. Weber Test: Tuning fork of 512 cps is set to vibrate and placed perpendicularly on the midline vertex of the skull. Client asked to report in which ear sound is heard. If heard in one ear, suspect sensorineural loss in the other
4. Rinne Test: Compares sound conduction - air versus bone 

• Set tuning fork to vibrate
• Place on mastoid process
• Ask client whether the sound is heard and when it can no longer be heard. Note how long the sound can be heard
• When client states that sound  is gone, immediately move the tuning fork to about 2 cm from auditory canal
• Ask the client again whether there is sound and when it stops 
• Normal finding: latter sound should be heard twice as long as that of mastoid sound

VI. Geriatric Alterations

• Ear lobes may appear pendulous
• Presbycusis

Physical Exam: Eyes

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I. History

• Current findings
• Past problems
• Family History - Glaucoma, Cataracts
• Harmful Exposure - Chemical Sunlight

II. Physical Exam

• Vision Test
• Extraocular Muscle Functions (EOMs)
• External Eye Structures
• Internal Eye Structures and Red Reflex
• Optic Disc
• Retinal Vessels

III. Geriatric Alterations of Eye

• Arcus Senilis - Opaque white ring about the periphery of the cornea, seen in aged persons; caused by the deposit of fat granules in the cornea or by hyaline degeneration
• Pupils often miotic (smaller) with slower dilatation
• Iris may appear paler
• Retina may appear paler
• Disc may be slightly smaller and more opaque
• Presbyopia
• Color perception may be dimmed